Provider Demographics
NPI:1386035731
Name:TIERNEY, KYLE (DPT)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:TIERNEY
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 WESTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:MT
Mailing Address - Zip Code:59840-2345
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1200 WESTWOOD DR
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:MT
Practice Address - Zip Code:59840-2345
Practice Address - Country:US
Practice Address - Phone:406-375-4570
Practice Address - Fax:406-375-4592
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-06
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAPTP-PT-LIC-11000225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT200021830Medicaid
IAIB1212040Medicare PIN
IAIB1213Medicare PIN
IAIB1212Medicare PIN